This article was first published on August 17, 2022.

More than half of people with monkeypox in the United States are now Black and Latino men who have sex with men, according to the latest demographic data from the Centers for Disease Control and Prevention (CDC). The shift toward gay and bisexual men of color increasingly mirrors long-standing disparities in the U.S. HIV epidemic.

“We’re creating a caste system of who is going to get access to what is needed for monkeypox,” longtime AIDS activist Gregg Gonsalves, PhD, now at the Yale School of Public Health, told PBS. “What we’re seeing is that the health disparities we’ve seen in COVID, we’ve seen in HIV, are recapitulating themselves with this new virus.”

As of August 16, the CDC has identified 12,689 monkeypox cases in the United States. Worldwide, there are now more than 38,000 cases, most of them in countries where monkeypox had not been reported prior to this outbreak.

While anyone can get monkeypox through close physical contact, cases remain overwhelmingly concentrated among gay, bisexual, transgender and other men who have sex with men. A new report from the CDC shows that 99% of cases with available data were among men, and 94% reported sex or other close intimate contact with other men.

The current monkeypox outbreak outside countries in Central and West Africa was first reported in May in the United Kingdom, with cases soon appearing in major cities in Europe, Canada and the United States. While many of these early cases were among white men who reported international travel, the picture has since shifted.

As of July 27, the CDC had received case reports with demographic data for just 1,195 (41%) of the 2,891 cases identified at that point, highlighting major gaps in reporting by states. Of the cases with available race and ethnicity data, 41% were white, 28% were Latino and 26% were Black. 

[UPDATE: On August 18, CDC director Rochelle Walensky, MD, PhD, gave reporters an update on the racial and ethnic distribution. With demographic data now available for more than 6,000 cases, 35% are white, 33% are Latino and nearly 28% are Black, showing a further shift toward people of color.]

For comparison, the U.S. Census Bureau estimates that the population is 59% white, 19% Latino, 14% Black and 6% Asian or Pacific Islander. Among people living with HIV in 2019, 29% were white, 25% were Latino, 40% were Black and 2% were Asian or Pacific Islander. Among gay and bisexual men newly diagnosed with HIV in 2019, 25% were white, 32% were Latino and 37% were Black.

The CDC report may actually understate these disparities, as some jurisdictions with greater racial and ethnic diversity have not submitted detailed case data to the CDC. What’s more, the proportion of Black and Latino people relative to white people with monkeypox has risen in recent weeks, and the report covers less than one tenth of the current case tally.

The national monkey public health emergency announced on August 4 could encourage more states to share their data with the CDC. “This public health emergency will allow us to explore additional strategies to get vaccines and treatments more quickly to impacted communities, and it will allow us to get more data from jurisdictions so we can effectively track and attack this outbreak,” new national monkeypox response coordinator Bob Fenton told reporters during a media briefing. 

Some state and local disparities are even more stark.

New York City, with a population of about 8.5 million, has reported 2,431 monkeypox cases as of August 16. Among those with available race/ethnicity data, 34% are Latino, 32% are white, 29% are Black and 4% are Asian or Pacific Islander. For comparison, the city’s population is 29% Latino, 32% white, 24% Black and 14% Asian or Pacific Islander.

[UPDATE: On August 18, New York City released new information about monkeypox vaccine distribution. So far, 46% of vaccines have gone to white residents, 23% to Latinos, 12% to Black residents and 10% to Asians and Pacific Islanders.]

San Francisco, with a population of about 800,000, has reported 600 cases as of August 16. Among those with available race/ethnicity data, 46% are white, 28% are Latino, 10% are Asian, 5% are Black and 6% are multiracial. The city’s population is 40% white, 15% Latino, 35% Asian or Pacific Islander, 5% Black and 7% multiracial. Thus, the proportion of cases among Latinos is about double their share of the population.

Los Angeles County reports 962 monkeypox cases in a population of about 9.8 million. Of the cases with available data, 37% are Latino, 35% are white, 11% are Black and about 7% are Asian, Pacific Islander, multiracial or other. The county’s population is 49% Latino, 25% white, 9% Black and 16% Asian or Pacific Islander. Although Latinos account for the largest percentage of cases, it falls below their share of the population.

Chicago (population 2.7 million) reports 694 cases, of which 43% are white, 31% are Latino, 19% are Black and 4% are Asian. The city’s population is 33% white, 29% Latino, 29% Black and 7% Asian. Here, whites are overrepresented and Blacks are underrepresented relative to their share of the population.

Washington, DC, has reported 344 cases as of August 16, but with a population of 670,000, it has the highest number of cases per capita after San Francisco. The city’s population is 46% Black, 37% white, 12% Latino and 5% Asian or Pacific Islander, but DC Health has not yet provided a demographic breakdown of monkeypox cases.

Some of the greatest monkeypox disparities are seen in the South.

Georgia has reported 1,013 cases as of August 16. Among 466 cases with available data, 82% are Black, 14% are white, 6% are Latino and about 5% are Asian, multiracial or other, according to an August 8 provider webinar. What’s more, 67% are living with HIV. The location of cases was not given, but a majority are around Atlanta (population 500,000), which is 50% Black, 38% white and 5% Latino. Black people are also heavily overrepresented among HIV cases in Georgia, at 73%.

[UPDATE: On August 17, Georgia released new data showing that Black people account for 71% of monkeypox cases but have received 46% of administered vaccines. White people, who make up just 12% of cases, have received nearly the same proportion of vaccines (45%).]

“I wish I could say I was shocked by this. I’m extremely concerned about it. But the most cynical part of me says it’s just another day in Georgia,” Melanie Thompson, MD, of the AIDS Research Consortium of Atlanta, told Georgia Public Broadcasting. “The disproportionate impact on this community is no surprise, and it’s been that way for decades…monkeypox, again, raises the veil on the disparities that occur in our health system.”

Vaccine Equity 

Monkeypox is related to smallpox but is less severe, and smallpox vaccines can prevent monkeypox too. Because the monkeypox virus has a long incubation period, vaccines may be used either as post-exposure prophylaxis (PEP) within several days after exposure or as pre-exposure prophylaxis (PrEP) for those at risk.

A safe nonreplicating smallpox and monkeypox vaccine (brand names Jynneos and Imvanex) was approved in 2019. It is normally administered as two doses given four weeks apart, but in an effort to stretch the severely limited vaccine supply, the Food and Drug Administration issued an emergency use authorization that allows the vaccine to be administered by intradermal rather than subcutaneous injection, enabling providers to split a single vial into five doses.

North Carolina (population 10.5 million) has reported only 180 monkeypox cases so far. But unlike most other jurisdictions, the state has reported its vaccination demographics. While 70% of cases are among Black men, African Americans have received less than a quarter of the 3,048 vaccines provided through August 8. In contrast, white people, who account for 19% of cases, have received 67% of administered vaccines.

Bloomberg reporters attempted to collect data on vaccination demographics, reaching out to health departments in 10 large cities in July. Only Washington, DC, shared data, revealing that 64% of vaccine recipients were white. Relying on Freedom of Information Act requests, they found that 55% of vaccines in Chicago and 54% in the Atlanta metro area went to white people.

Despite the lack of formal reporting by the CDC or local and state health departments, vaccination disparities are apparent in anecdotal reports. In New York City, for example, vaccines were first offered at a clinic in the heavily gay Chelsea neighborhood, and the news largely spread by word of mouth. Even when the city opened a second vaccination site in Harlem, those waiting in the queue were mostly white men. In many cities, vaccine distribution has favored people who can easily navigate websites or are able to wait in line on weekdays.

Some cities have made efforts to make vaccines more available to underserved groups. The San Francisco Department of Public Health is working with organizations that serve Black, Indigenous and people of color communities and has reserved some vaccine slots for the heavily impacted Latino community. The Georgia Department of Public Health is working with Atlanta Black Pride to distribute vaccines during upcoming events, and Howard Brown Health in Chicago opened two vaccination sites in the city’s predominantly Black South Side and has set up pop-up sites at Black queer events, according to Bloomberg.

“Vaccine inequity hurts our efforts to stop monkeypox,” former CDC director and New York City health commissioner Tom Frieden, MD, MPH, said on Twitter. “We need to direct limited vaccines to the communities most at risk. Right now in the U.S., data show Black, Latino and HIV-positive men who have sex with men are being infected at disproportionately high rates.”

Vaccination is indicated for people who have had known close contact with a person with monkeypox as well as for those at risk for exposure. So far, this has mostly meant gay and bisexual men with multiple recent sex partners and those who attended venues or events where exposure might have occurred. Some jurisdictions include transgender people, sex workers of any gender or orientation and people who are eligible for PrEP to prevent HIV.

Washington, DC, was recently the first to expand vaccine eligibility to include people of any sexual orientation or gender who have had multiple sex partners during the past two weeks. While monkeypox cases remain rare among cisgender women and heterosexual men, expanding eligibility—and basing it on behavior rather than identity—could help reach people who are at risk but don’t consider themselves gay or bisexual and those who are hesitant to disclose their orientation to health officials or providers.

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